Have you ever seen or read your medical records? For most of us, that answer is likely “no.” Yet, any time you receive medical care, your provider prepares written notes documenting the care and treatment you received. In the case of possible medical negligence or malpractice, your medical records become a critical source of information, which we rely on to establish your medical and treatment history and to identify any potential provider errors. Given the importance of medical records in this regard, you should know the following:
You have a right to your medical records. According to the Department of Health and Human Services, only you or your personal representative has the right to access your records. A provider cannot refuse to provide you with a copy of your records for any reason, including failure to pay for medical services. However, providers are permitted to charge you a reasonable fee for copying and mailing your records. If you’re a parent, you’re typically able to request your children’s records, except in certain cases such as when the state has given the child consent authority for treatment or a child has obtained treatment at the direction of a court or its appointed representative.
There are a few ways to obtain your medical records. The simplest and quickest way is usually for you to request your records from the physician or hospital directly. Each medical facility has its own method of requesting records. You will typically need to submit a signed letter or fill out a request form. Another way is for your attorney to request the records on your behalf. This process takes longer and is often more expensive.
Ask for your full medical record. Many facilities will ask what “part” of your records you want. In most cases, you’ll want to ask for your complete chart. While you will likely be asked to cover copying costs, there is a federal law that limits the amount a provider can charge is you request for the release of your records in electronic format. If you have questions on what to request, consult your attorney.
Make a practice of retaining medical records you’re given or accessed. Whether or not you anticipate a potential medical malpractice case, it’s a good idea keep a file of the medical documents you’ve been given or requested along the way. Examples would be discharge reports, prescriptions, lab test results, and any diagnosis and treatment-related records.
Medical records are primary evidence for you and your physician. Remember that your medical facility and doctor will also be using your medical records in their defense. It’s not unprecedented for records to be amended after a serious medical error, so you’ll want to preserve them quickly. Remember, you do not have to give a reason to request your records. Obtaining them is your right.
For more information on your medical record rights in Massachusetts, see state guidance here. If you suspect you or a loved one has been a victim of medical malpractice, consulting an attorney as soon as possible can make the difference.